Lifeline Systems Inc
| | This is a FOLLOW-UP Install; Number of pages |Program Name |Program Phone Number |
|This is a PARTIAL Install |included: |LIFELINE OF NEGMC |770-219-8899 |
|(Must complete all |1 or 2 | | |
|fields outlined in bold) | | | |
|Program Code |Model Type |Unit # |Household Phone # |Installation Date |
|GA037 | | |( ) | |
| | | | | |
|Salutation |Subscriber Last Name |First Name |Middle |Suffix |
| | | | | |
| | | | | |
|Preferred Name |Last Name Sounds Like |Language Need? |Gender |Date Of Birth |
| | | | | |
| | |Spanish Other |Male Female | |
|Household Information |Emergency Phone Numbers (Do not list 911 or 800 #’s) |
|Residential Street Address/Apt.# |CENTRAL DISPATCH ( ) |
| | |
| |POLICE ( ) |
|City |State |Zip Code |FIRE ( ) |
|Township/Municipality |County | AMBULANCE Check if Private ALTERNATE AMBULANCE |
| | |( ) ( ) |
|Household Hidden Key Location |Directions To Home (Must Be Provided If PO Box Listed) |Additional Services |
| | | Healthcare Directives |
| | |Inactivity Alarm Service |
| | |Special Instructions |
| | | State Funded |
| | |Lifeline Smoke Detector |
|Drug Allergies |Medical Conditions and/or Diseases |Household Warning |
| | | | |
| | | | |
|Responder One |Responder Two |Responder Three |
|Name (First/Last) |Name (First/Last) |Name (First/Last) |
|Language Need? |Language Need? |Language Need? |
|Spanish Other |Spanish Other |Spanish Other |
|Street Address |Street Address |Street Address |
|City, State, Zip Code |City, State, Zip Code |City, State, Zip Code |
| | | |
|Family Relation | Have Key |Family Relation | Have Key |Family Relation | Have Key |
| |Family Caregiver | |Family Caregiver | |Family Caregiver |
| |Notify | |Notify | |Notify |
| |Reminder Contact | |Reminder Contact | |Reminder Contact |
|Phone Home Work Cell |Phone Home Work Cell |Phone Home Work Cell |
| | | |
|( ) |( ) |( ) |
|Phone Home Work Cell |Phone Home Work Cell |Phone Home Work Cell |
| | | |
|( ) |( ) |( ) |
|Phone Home Work Cell |Phone Home Work Cell |Phone Home Work Cell |
| | | |
|( ) |( ) |( ) |
|Program Code |Subscriber Last Name |First Name |Household Phone # |Program Name |
| | | | | |
|GA037 | | |( ) |LIFELINE OF NEGMC |
|Notify |Notify |
|Name (First/Last) |Family Relation |Name (First/Last) |Family Relation |
| | | | |
| |Family Caregiver | |Family Caregiver |
| |Reminder Contact | |Reminder Contact |
|Phone Home Work Cell |Phone Home Work Cell |Phone Home Work Cell |Phone Home Work Cell |
|( ) |( ) |( ) |( ) |
|Primary Physician |Third Party Notify |
|Name (First/Last) |Name (First/Last) |Fax Number |
| | | |
| | |( ) |
|Phone |Name (First/Last) |Fax Number |
|( ) | | |
| | |( ) |
|Preferred Hospital |Referral Source |
|Hospital Name |Name (First/Last) |Phone |
| | | |
| | |( ) |
|City, State |Phone (REQUIRED) |Organization/Agency Name |Position/Title |
| | | | |
| |( ) | | |
| Multiple Subscriber Household |Street Address |City, State, Zip Code |
|(You must complete a separate Care Plan Agreement for each Subscriber) | | |
| | | |
|Name of Additional Subscriber | | |
| | | |
| | | |
| |Coupon Code | | |
| | – |
| | |
| |Referral Source Code Promotion Code |
|Subscriber Notes |
|Payer Information |
|First Name (If applicable organization name) |Last Name |Home Phone # |
| | | |
| | |( ) |
| | | |
|Street Address | |Work phone # |
| | | |
| | |( ) |
| | | |
|City |State |Zip Code |Social Security Number |Medicaid Number |
| | | |XXXXXXXXXXXXXXX | |
|Monthly Fee(s) | |One Time Fee(s) | |Payment Frequency |Payment Method |
|Monitoring Service |$XXXX |Enrollment Fee |$No Charge |X Monthly |X Invoice |
|Inactivity Service |$XXXX | |$XXXX |Quarterly |Credit Card |
| |$ |Shipping & Handling | |Yearly |Debit Card |
|Card Type |Name (as it appears on Card) |Card Number |Expiration Date |
|X Visa | | | |
|X Master Card |XXXXXXXXXXXXXXXXXX |XXXXXXXXXXXXXXXXXXXXX |XXXXXXXXXXXX |
|X American Express | | | |
|X Discover | | | |
|For Program Use Only (Not to be Entered by Data Entry) |
| |
|Signature Of Subscriber Date |Signature Of Payer (If Different) Date |
| | |
| | |
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